Medicare patients can't get 'cancer pill'

Rapid progress continues on oral chemotherapy treatments that are far more effective and less toxic than conventional alternatives, but the inability of Medicare and insurance companies to offer comparable coverage is draining the resources of many patients and leaving others unable to pursue treatment.

The mapping of the human genome has allowed doctors to determine which parts of cells are compromised by cancer and responsible for spreading it. As a result, oral chemotherapy allows for much more effective treatment against killers like myeloma, breast cancer and pancreatic cancer. It’s also far less toxic than traditional chemotherapy because the targeting of the medication requires far smaller dosages that wreak far less havoc on the immune system.

“What we’re seeing as a result of the new oral medicines is what we saw with HIV when you give a combination of treatments that’s matched to the way your genes respond to the disease and drug and you’re saving lives of people who otherwise would be dying early,” said Robert Goldberg, founder and vice president of the Center for Medicine in the Public Interest, who wrote on the promise and financial frustration of these advancements in the May 8 edition of the New York Post.

So why are Medicare and insurance companies content to cover virtually the entire tab for conventional chemotherapy but not for the more effective and less harrowing oral drugs? Goldberg told WND it mostly comes down to money.

“There’s this disconnect between medical innovation and how insurance and Medicare are paying for things. First, it’s easier to get more payment for injections than it is to get for oral medications. Also physicians tend to get reimbursed more for injections than they do for dispensing a pill. They actually get paid for infusing, whereas for running a prescription there’s no extra fee that they can collect,” Goldberg said. “The second reason is, unfortunately, an obvious one. If you can shift the cost to the consumer, you see just how much you can get away with paying.

“It’s been hurting many, many patients. Twenty-five percent of all patients don’t even fill their prescriptions for these products at the first crack. Many doctors are putting people on less effective and less personalized medicine because it’s not affordable. Because these medicines keep people out of the hospital and extend their lives with less toxicity, they’re actually saving money. So in effect, the oral medicines are being subsidized by consumers and they’re saving insurers money,” Goldberg said.

While Goldberg is frustrated by the lack of coverage for oral chemotherapy, he strongly rejects assertions by the New York Times and others that the real problem is how much drug companies are charging for the medicine in the first place. In a May 2 editorial, the Times points out many oral chemotherapy drugs cost upward of $100,000 per year. The editorial references a group of oncologists that considers those costs as “profiteering, like jacking up the price of necessities after a natural disaster.”

Goldberg said that blame is wrongly placed.

“I’m hoping that over the next few months and into the campaign season that we will have a discussion about what the value of medical innovation really is and we get off this silly attack on prices from the New York Times and from physicians and focus on the value,” Goldberg said. “The value of people living longer and added income and better health and less disability is about $4.2 trillion over the life of an individual, collective lives. Drug spending is about one percent of all that. So it’s a great, great investment that goes to the bottom line that matters most, which is having more time on the planet to do the things you love and be with the people you care for.”

Goldberg is also hopeful that a solution to the coverage problems on oral chemotherapy drugs is near. He is strongly supportive of the Cancer Drug Coverage Party Act sponsored by Rep. Brian Higgins, D-N.Y.

“You’re not telling the companies what to use, but at least give the insurance companies and consumers a choice based upon what’s best for them. I think that’s a pretty straightforward proposition,” Goldberg said. “This is a smart 21st century way to reform health care, and I’m hoping that this is just the beginning of reforming health care around what people want and what people can do rather than what the government wants the rest of us to do.”

Goldberg said the bill has bipartisan support, and the Congressional Budget Office has recently alleviated concerns that this legislation would result in additional federal spending through Medicare and other programs.

“To spend something in Washington, in theory you’re supposed to cut somewhere else. Well the Congressional Budget Office has finally realized that if you spend money on these new medications, you’re going to save money by what you don’t spend in hospitalizations and having to deal with hospice and so on which are also very very expensive,” he said.

The Cancer Drug Coverage Parity Act of 2013 was introduced April 26. It has been referred to the House Energy & Commerce, Ways & Means and Education & Workforce Committees for consideration. The bill is officially known as H.R. 1801.